Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Saying No, Well

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Clearly, not fulfilling patients' requests diminishes their satisfaction, but patient-centered communication can enhance that. So what is one to do? Being adept at saying "no" is an art; it should preserve, if not amplify a practitioners' interest in and concern for their patient. This article describes ways of negotiating with patients about specific requests for diagnostic testing, treatment, on-going or changing care.

As the Care Improves, So Does the Cost

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To those of us in primary care and our patients, chronic diseases are insidiously costly to body, soul and pocketbook. And, watching a patient with an otherwise manageable illness develop complications that are avoidable or that can be delayed is entirely pathetic. "Not only is this a tragedy for the patient, but it is also a tragedy for our healthcare system as a whole. The actual monetary costs of the sequelae of diabetes are astronomical.

The Way of Malpractice

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Getting sued for malpractice can make any practitioner overly practice defensively, which is not the same as more effectively and certainly not more cost-effectively.  Abstract "Despite widespread agreement that physicians who practice defensive medicine drive up health care costs, the extent to which defensive medicine increases costs is unclear. The differences in findings to date stem in part from the use of two distinct approaches for assessing physicians' perceived malpractice risk.

Dysfunctional Liability System

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See Defensive medicine has been highlighted as a major driver of health care costs here and elsewhere.  It probably is when you consider the indirect costs (how it changes the way we practice).   Along comes the Accountable Care Organization Are ACOs Subject to More or Less Liability? Yes, and it is instructive to review why and how they are different.

Managed Care Organizations Practicing Medicine (Without a License)

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Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs.  Not long ago, Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium; Reason? This drop, containing an antibiotic and a steroid was not available generically; they were forcing me to use a plain ear drop – not what the doctor ordered! Mental Health Parity; Let the HMO's Be Damned!

Managed Care Organizations Practicing Medicine (Without a License)

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Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs.  Not long ago, Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium; Reason? This drop, containing an antibiotic and a steroid was not available generically; they were forcing me to use a plain ear drop – not what the doctor ordered! Mental Health Parity; Let the HMO's Be Damned!

Quality/Cost, International Comparisons -- OUCH!

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The following lists are from healthsprocket.com.  Note that the US ranks at the bottom of 19 industrialized countries in preventable deaths/100,000 population. Top 25 countries with the best healthcare systems The Top 10 Medical Travel Destinations How the Performance of the U.S. Health Care System Compares Internationally (Health Expenditures/Capita) Health Expenditures per Capita - Seven Selected Countries

Really Poor Performance, U.S.A.!

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Beyond our obvious quality problems.... Yearly, approximately 100,000 patients die of health care–associated infections, about another 100,000 die from other preventable errors, and "tens of thousands more die of diagnostic errors or failure to receive recommended therapies."1-3 But, That’s Just the Obvious Quality Problems.  Possibly Related Is That Our Mortality Rates Pale In Comparison to Other Industrialized Countries

When Practitioners Collaborate, It Can Clinically Help, Financially Hurt or Both

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Is it the patient's fault when they end up getting needed care out-of-network, i.e., from physicians who aren't part of the managed care network, the referral list is too thin or restrictive, the right specialist is elsewhere (or so it seems), or simply because there was no opportunity to choose an in-network doctor? Referrals Tell Us a Great Deal About Collaboration Among Practitioners

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